Devices, systems and methods for meniscus repair

ABSTRACT

Described herein are meniscus suture passers for repair of the meniscus of the knee. These devices are typically suture passers that may include an elongate body having a pair of arms. One or more of the arms may be angled or bent at the distal end region relative to the long axis of the device, forming a distal-facing opening that is configured to fit meniscus tissue. One or both arms may be movable in the axial direction (e.g., the direction of the long axis of the device). The devices typically include a tissue penetrating element housed within one of the arms but configured to extend across the distal opening between the arms. Thus, a suture may be passed from a first side of the tissue to a second side.

CROSS REFERENCE TO RELATED APPLICATIONS

This patent application claims priority to U.S. Provisional PatentApplications: Ser. No. 61/259,572, titled “DEVICES, SYSTEMS AND METHODSFOR MENISCUS REPAIR” filed Nov. 9, 2009; Ser. No. 61/295,354, titled“DEVICES, SYSTEMS AND METHODS FOR MENISCUS REPAIR” and filed on Jan. 15,2010; and Ser. No. 61/318,215, titled “CONTINUOUS SUTURE PASSERS HAVINGTISSUE PENETRATING SUTURE SHUTTLES” filed on Mar. 26, 2010. All of theseapplications are herein incorporated by reference in their entirety.

This application may also be related to U.S. patent application Ser. No.11/773,388, titled “METHODS AND DEVICES FOR CONTINUOUS SUTURE PASSING,”and filed on Jul. 3, 2007; and U.S. patent application Ser. No.12/291,159, titled “SUTURE PASSING INSTRUMENT AND METHOD,” filed on Nov.5, 2008. Both of these applications are herein incorporated by referencein their entirety.

INCORPORATION BY REFERENCE

All publications and patent applications mentioned in this specificationare herein incorporated by reference in their entirety to the sameextent as if each individual publication or patent application wasspecifically and individually indicated to be incorporated by reference.

FIELD OF THE INVENTION

The devices, systems and methods described herein may be useful for thesurgical repair of a torn meniscus. In particular, described herein aresuture passers that are adapted for the effective and reliable passingof a suture to repair a torn meniscus.

BACKGROUND OF THE INVENTION

The meniscus is a C-shaped piece of fibrocartilage which is located atthe peripheral aspect of the joint (e.g., the knee). The central ⅔^(rds)of the meniscus has a limited blood supply while the peripheral ⅓^(rd)typically has an excellent blood supply. Young patients typically teartheir menisci from traumatic events while degenerative tears are commonin older patients as the menisci become increasingly brittle with age.Typically, when the meniscus is damaged, the torn piece begins to movein an abnormal fashion inside the joint, which may lead to pain and lossof function of the joint. Early arthritis can also occur due to thesetears as abnormal mechanical movement of torn meniscal tissue and theloss of the shock absorbing properties of the meniscus commonly lead todestruction of the surrounding articular cartilage. Occasionally, it ispossible to repair a torn meniscus. While this may be donearthroscopically, surgical repair using a suture may be difficultbecause of the difficult-to-reach nature of the procedure and thedifficulty in placing sutures in a way to compresses and secures thetorn surfaces.

Arthroscopy typically involves inserting a fiberoptic telescope that isabout the size of a pencil into the joint through an incision that isapproximately ⅛ inch long. Fluid may then be inserted into the joint todistend the joint and to allow for the visualization of the structureswithin that joint. Then, using miniature instruments which may be assmall as 1/10 of an inch, the structures are examined and the surgery isperformed.

FIGS. 2A-3 illustrate the anatomy of the meniscus in the context of aknee joint. As shown in FIG. 3 the capsule region (the outer edge regionof the meniscus) is vascularized. A typical meniscus has a flattened(“bottom”) and a concave top, and the outer cross-sectional shape issomewhat triangular. The outer edge of the meniscus transitions into thecapsule. FIG. 4 illustrates the various fibers forming a meniscus. Asillustrated in FIG. 4, there are circumferential fibers extending alongthe curved length of the meniscus, as well as radial fibers, and morerandomly distributed mesh network fibers. Because of the relativeorientations and structures of these fibers, and the predominance ofcircumferential fibers, it may be beneficial to repair the meniscus bysuturing radially (vertically) rather than longitudinally(horizontally), depending on the type of repair being performed.

For example, FIGS. 5A-5E illustrate various tear patterns or injuries toa meniscus. Tears may be vertical/longitudinal (FIG. 5A), Oblique (FIG.5B), Degenerative (FIG. 5C), including radially degenerative, Transverseor radial (FIG. 5D) and Horizontal (FIG. 5E). Most prior art devices forsuturing or repairing the meniscus are only capable of reliablyrepairing vertical/longitudinal tears. Such devices are not typicallyrecommended for repair of radial tears, particularly notarthroscopically/minimally invasively. FIGS. 6A-6C illustrate suturesplaced with prior art devices to repair (via suturing) a torn meniscus(showing a longitudinal tear). FIG. 6A illustrates the results of arepair by a Smith&Nephew “Fast-T-Fix” device (comparable to a repair bya Biomet MaxFire device). FIG. 6B illustrates a Cayanne “CrossFix”device, and FIG. 6C illustrates a repair using an Arthrex meniscal“Viper” device.

In FIGS. 6A-6C the devices affecting these repairs require projectionthrough the meniscus and substantially into the capsule region outsideof the meniscus, which could potentially damage the nearby major nervesand large blood vessels. Further, the prior art devices, such as thoseplacing the sutures illustrated in FIG. 6A-6C, typically placehorizontal mattress suture patterns rather than vertical mattress suturepatterns because vertical patterns are considerably more difficult forsurgeons to place when using these devices. Vertical mattress patternswould have improved pull through strength because of the aforementionedpredominance of circumferential collagen fibers found within themeniscus structure. Additionally, the devices forming the suturepatterns illustrated in FIG. 6A-6C are only capable of point fixation;that is they cannot compress the tears uniformly across the tornsurface. Finally, such prior art devices are designed for repairingperipheral vertical meniscus tears (torn from the superior surface tothe inferior surface in line with the C-shape of the meniscus) and areincapable of repairing commonly encountered radial meniscus tears.

Thus, there is a need for methods, devices and systems for repairing atorn meniscus that are compatible with effective suturing. Inparticular, it would be beneficial to provide a device capable ofsuturing both radial and longitudinal tears. The methods, devices andsystems described herein may address this need.

SUMMARY OF THE INVENTION

Described herein are methods, devices and systems for repairing a tornmeniscus. In particular, described herein are methods of repairing ameniscus that has a peripheral vertical meniscal tear or a peripheralradial meniscal tear that are compatible with arthroscopic (minimallyinvasive or semi-minimally invasive) techniques.

In general, the meniscus repair suture passer devices described hereinare configured as continuous suture passers that may pass a suture backand forth between two arms or jaw between which the tissue (e.g.,meniscus or adjacent tissues) is positioned. A meniscus repair suturepasser may include a first arm (which may also be referred to as a lowerarm) that is axially slideable relative to a second arm (which may alsobe referred to as an upper arm). The device may also include a tissuepenetrator that extends between the arms, preferably in a curved orarcuate path. The tissue penetrator may alternately (cyclically) secureand release a suture (e.g., using a suture shuttle to which a suture maybe connected), allowing the tissue penetrator to pull and push thesuture shuttle between the first and second arm in cycles that alternatewith leaving the suture shuttle (or, in some variations, the sutureitself) in a dock, e.g., shuttle dock, on the arm that is opposite fromthe arm into which the tissue penetrator retracts into. These featuresmay allow the meniscus repair suture passer to continuously pass asuture back and forth through a tissue without requiring that thesuturing device be removed from the knee, or even removed off of themeniscus.

For example, described herein are meniscus repair suture passer devicesthat include: an elongate first arm extending distally and proximallyalong a long axis; an elongate second arm extending adjacent to thefirst arm along the long axis, wherein the first arm is axially movabledistally and proximally relative to the second arm along the long axis,further wherein the distal end region of the second arm bends away fromthe long axis to form a distal opening between the second and first armswhen the first arm is extended distally relative to the second arm; anda tissue penetrator configured to extend across the distal openingbetween the first and second arms to pass a suture therebetween. In somevariations the second arm is also axially movable (e.g., relative to therest of the device) along the long axis of the device. The suture may beconnected to a suture shuttle, and thus the tissue penetrator may beconfigured to releasably connect to a suture shuttle that may be coupledto the suture.

The “arms” of the suture passer devices described herein may also bereferred to as “jaws” or “members”. Although in some variations the armsare elongate members, they may also be short members; the arms do notneed to (although one or both of them may) extend the length (e.g., thelength of the long axis) of the device. In some variations one or botharms may also be referred to as a shaft. For example, the second arm(“upper arm”) may be referred to as an elongate shaft. In somevariations the upper and lower arms may be included as part of anelongate shaft extending from the proximal to the distal end of thedevice.

The devices described herein may include a plurality of different axes,including a long axis. The long axis may be the longest axis of thedevice, or it may be long axis of the device not including the handleregion, or some other sub-region of the device. For example, the longaxis may define a proximal-to-distal axis of the device. The distal endof the device typically faces away from the handle, towards the patient,while the proximal end of the device typically faces a practitionerholding the device; the proximal end of the device may include a handle,while the distal end of the device engages tissue (e.g., the meniscus).

In general the first and second arms are axially movable (along theproximal-distal long axis) relative to each other, and/or relative tothe rest of the device (e.g., a handle, an elongate housing or bodyregion, etc.). In some variations the first arm is extendable ormoveable along the long axis of the device relative to the second arm.The second arm may be fixed relative to the rest of the device, or itmay also be axially movable relative to the long axis of the rest of thedevice. Conversely, the second arm may be axially movable or extendablerelative to the first arm, which may be fixed (not movable) relative tothe rest of the device or also axially movable or extendable. Axialmotion may be referred to as sliding, pushing, pulling, or the like.This motion is typically in the proximal/distal direction, along thelong axis. For reference, the motion of the tissue penetrator asdescribed herein may (in some variations) be in an axis that istransverse to the long axis of the device.

A tissue penetrator is typically an elongate member that passes throughthe tissue and may push and/or pull a suture shuttle with it. Althoughin some variations the tissue penetrator may directly connect to asuture, in the principle embodiments described herein the tissuepenetrator is configured for indirect coupling with a suture via asuture shuttle. This is described in greater detail below. A tissuepenetrator may be solid or hollow, and may be curved, straight orbendable/curveable. In some variations the tissue penetrator has a sharpand/or pointed distal end. In some variations the tissue penetrator hasone or more regions for engaging a suture or suture shuttle. Forexample, the tissue penetrator may include a clamping or anchoringregion for releasably securing a suture shuttle.

In general, the first and second arms of the meniscus repair suturedevices described herein may be positioned to form an opening(preferably an acute angled opening such as a v-shaped opening) when thefirst arm is extended relative to the second arm. This opening may beconfigured to correspond (or be slightly wider than) the angle of thesuperior surface and inferior (undersurface) of a meniscus. Asmentioned, the meniscus are typically C-shaped fibrocartilaginousstructures attached to the condylar surface of the tibia. The limbs ofthe C face centrally. The superior meniscal surface is generallyconcave, which enhances contact with the curvilinear-shaped femoralcondyle. Conversely, the undersurface of the meniscus is generally flat,which enhances contact with the flattened tibial plateau. The periphery(outer portion) of the meniscus is thicker than the pointed centralportion. The thick periphery allows for a firm attachment to the jointcapsule. Thus, in general, the first and second arms of the devicesdescribed herein may be configured to fit this generic anatomy (and maybe sized to fit specific anatomies or ranges of anatomies). For example,the first arm may be straight and configured to fit beneath the flatundersurface of the meniscus, while the second arm forms a bend with thefirst arm approximating the angle between the superior surface andundersurface of the meniscus (e.g., the maximum angle, or an average ofthe angle of this somewhat convex surface).

For example, the distal opening of the devices formed between the firstand second arms may be an acute-angled distal facing opening configuredto fit the meniscus therein. The distal opening may be a v-shaped distalopening between the second and first arms when the first arm is extendeddistally relative to the second arm, configured to receive a meniscus.

In general, when the first arm, which is typically “straight” orextending in the same direction as the long axis of the device, isretracted proximally, the lower “arm” of the distal opening is missing,so the device has just a narrow, bent, distal end formed by the distalend region of the second arm. This distal end region may be used toposition the device within the knee near the meniscus. The small sizeand dimensions of the distal end when the first arm is retractedproximally (completely) may allow the device to navigate the tissue ofthe knee without undue damage to other tissues. Extending the first(lower) arm distally may form the “v-shape” mentioned above. In general,the tips of the distal ends of the second and first arms are rounded andatraumatic. In particular, the tips may be blunt to prevent damage totissue as the device is positioned.

In some variations, the tissue penetrator is configured to be housedwithin the distal end of the first arm. The tissue penetrator may becompletely retracted into the first arm, which may prevent damage totissue as the device is maneuvered into position around the meniscus. Insome variations, the tissue penetrator is configured to extend from thesecond, rather than the first arm, in which case the configuration ofthe tissue penetrator and dock (e.g., shuttle dock) may be reversed.

The meniscus repair suture devices described herein may also include aproximal handle having a first control for axially moving at least thedistal end region of the first arm relative to the second arm. Aproximal handle may be configured for gripping (in a single hand orusing both hands), and may have a tissue penetrator control forcontrolling the extension and retraction of the tissue penetrator acrossthe distal opening formed by the second arm and the extended first arm.

As mentioned, a meniscus repair suture device may also include a dock atthe distal end region of the second arm configured to alternatelyrelease and retain the suture, permitting the tissue penetrator to passthe suture from the first arm to the second arm and back to the firstarm. In some variations, this dock is a shuttle dock that is configuredto releasably secure a suture shuttle (to which a suture may be directlyor indirectly connected) for exchange between the tissue penetrator(which may ferry the shuttle dock and any connected suture) back andforth between the first and second arms, alternately leaving the sutureshuttle in the shuttle dock on the arm opposite from the arm to whichthe tissue penetrator is attached and housed.

Thus, in some variations the meniscus repair suture device also includesa shuttle dock at the distal end region of the second arm configured toalternately release and retain the suture shuttle, permitting the tissuepenetrator to pass the suture shuttle from the first arm to the secondarm and back to the first arm. In variations in which the tissuepenetrator extends and retracts into the second arm, the first arm mayinclude a shuttle dock. In some variations the devices include aplurality of shuttle docks, e.g., at the distal end region of the secondarm, that are each configured to alternately release and retain thesuture shuttle, permitting the tissue penetrator to pass the sutureshuttle from the first arm to the second arm and back to the first arm.

The tissue penetrator may be configured to extend across the distalopening in a curved path. For example, the tissue penetrator may becurved or curveable (e.g., via a hinged region, shape-memory material,etc.). In general, the tissue penetrator may include a clip region towhich a suture shuttle may releasably secure.

Any of the devices described herein may be configured for re-use. Forexample, in some variations a portion of the device is “durable”(re-usable) and a portion of the device is disposable. For example, insome variations the second arm is configured to be detachable from thedevice, and disposed of. In some variations the second arm includes asuture shuttle and/or an attached suture that is pre-loaded into thesecond arm (or shaft). Thus, in some variations, the second arm isconfigured to be disposable and to detachably connect to a reusablefirst arm.

The first arm may be extended or retracted axially as mentioned above.In general, the first arm may include a final stop that limits orprevents the movement of the first arm distally along the long axis ofthe device by preventing the first arm from extending beyond this stop.For example, the final stop may prevent the distal tip of the first armfrom extending beyond a position on the device in which the tip of thefirst arm and the tip of the second arm form a right angle relative tothe long axis of the device, which may be the same as the long axis ofthe first arm.

In some variations, the devices described herein include a plurality of“stops” that indicate to a user the axial position of the first armalong the distal to proximal long axis of the device. These stops,unlike the final stop, may not prevent axial movement of the first armrelative to the device, but they may indicate positions in which thefirst arm of the device may be held static by some manner, or where aslight increase in resistance to axial motion may be felt. Thesepositions may correspond to known positions of the first arm relative tothe upper arm (e.g., fully withdrawn, extended halfway across thedevice, fully extended, or intermediate positions between these). Insome variations these stop positions may correspond to positions inwhich the tissue penetrator, if extended while the first arm is at thisstop position, will engage a shuttle dock.

Any of the devices and components described herein may be included aspart of a kit. For example, described herein are kits comprising ameniscus repair suture passer and a suture shuttle. In some variationsthe kit includes a suture. In some variations the kit may include aremovable (or multiple removable) second arm or shaft region. Thissecond arm may include one or more shuttle docks pre-loaded with asuture shuttle and/or suture.

Also described herein are meniscus repair suture passer device forpassing a suture through the meniscus, the device comprising: anelongate shaft extending distally and proximally along a long axis; afirst arm that is movable distally and proximally relative to the longaxis; wherein the shaft comprises an second distal end region that bendsaway from the long axis of the shaft to form a v-shaped distal openingwith the first arm when the first arm is extended distally; a tissuepenetrator configured to extend across the distal opening between thesecond and first arms in a curved pathway and to pass a suture shuttletherebetween; and a shuttle dock having an opening configured toalternately release the suture shuttle onto the tissue penetrator and toreceive and hold the suture shuttle from the tissue penetrator.

As mentioned, the shuttle dock may comprise a releasable lock configuredto alternately release the suture shuttle onto the tissue penetrator andto receive and hold the suture shuttle from the tissue penetrator. Theshuttle dock may be on the second distal end region of the shaft.

Also described herein are meniscus repair suture passer devices forcontinuously suturing tissue to repair a torn meniscus, including: anelongate first arm extending distally and proximally along a long axis,wherein at least the distal end of the first arm is axially movabledistally and proximally relative to the long axis; an elongate secondarm extending along the long axis, wherein the distal end region of thesecond arm bends away from the long axis to form a v-shaped distalopening with the first arm when the first arm is extended distally; atissue penetrator housed within the distal end region of the first arm,the tissue penetrator configured to extend across the distal openingbetween the second and first arms and pass a suture shuttletherebetween; and a shuttle dock at the distal end region of the secondarm configured to alternately release the suture shuttle onto the tissuepenetrator and to receive and hold the suture shuttle from the tissuepenetrator, permitting the tissue penetrator to pass the suture shuttlefrom the first arm to the second arm and back to the first arm.

Although many of the examples described herein describe meniscus repairsuture devices that are configured to indirectly couple with a sutureusing a suture shuttle, in some variations the device may be configuredto pass a suture back and forth through tissue without requiring ashuttle. For example, in some variations, the tissue penetrator isconfigured to releasably connect to a suture, to pull the suture acrossthe tissue a first time (e.g., from the second arm to the first arm) andthen, after repositioning the device relative to the meniscus, pushingthe suture across the tissue again (e.g., from the first arm to thesecond arm), where the suture may be released from the tissue penetratorinto a dock that retains the suture at the second arm.

Methods of repairing the meniscus using any of the meniscus repairsuture passer devices described herein are also described. For example,described herein are methods of repairing a torn meniscus using acontinuous suture passer having a first arm and a second arm and adistal to proximal long axis, the method comprising: placing the distalend region of the second arm of the suture passer adjacent to one sideof the meniscus, wherein the distal end region of the second arm is bentrelative to the long axis of the suture passer; extending the distal endregion of the first arm of a suture passer distally relative to the longaxis of the suture passer, wherein the first arm extends under anopposite side of the meniscus so that the distal end regions of thefirst and second arms of the suture passer form a v-shaped opening inwhich at least a portion of the meniscus is positioned; extending andwithdrawing a tissue penetrator across the opening between the first andsecond arms to pass a suture between the first and second arms;repositioning the suture passer without removing the suture passer fromthe meniscus; and extending and withdrawing the tissue penetrator acrossthe opening between the first and second arms to pass the suture betweenthe first and second arms a second time.

In some variations, the step of placing the distal end region of thesecond arm comprises placing the distal end region of the second armadjacent to the superior side of the meniscus. The second arm may beused to help position the first arm, using the tip of the second arm tocause the central aspect of the meniscus to flip upward a few degrees,allowing easier access for the first arm to slide under the meniscus(the inferior or undersurface of the meniscus). For example, the step ofplacing the distal end region of the second arm may include applyingoutward pressure on the capsule just superior to the peripheral meniscustissue.

The step of extending the distal end region of the first arm may includesliding the first arm distally relative to the long axis to position thetip of the distal end region of the first arm beneath the undersurfaceof the meniscus opposite from the superior surface.

The step of extending the distal end region of the first arm maycomprises sliding the first arm distally relative to the long axis to afully extended position. The step of extending the distal end region ofthe first arm may include sliding the first arm distally relative to thelong axis comprises extending the distal end region until a stop isreached.

In general, the steps of extending and withdrawing the tissue penetratorcomprise extending and withdrawing the tissue penetrator along a curvedpath between the first and second arms. The step of extending andwithdrawing a tissue penetrator across the opening between the first andsecond arms to pass a suture between the first and second arms maycomprise extending the tissue penetrator from within the first arm,through tissue, and engaging a shuttle dock within the second arm beforewithdrawing the tissue penetrator back into the first arm. In somevariations, the step of extending and withdrawing a tissue penetratoracross the opening between the first and second arms to pass a suturebetween the first and second arms comprises extending the tissuepenetrator from within the first arm, through tissue, and engaging asuture shuttle held within the second arm, and withdrawing the sutureshuttle secured to the tissue penetrator back into the first arm.

During use, the suture passer may be repositioned relative to themeniscus either by moving the entire suture passer, or by moving aportion of it (e.g., the first arm) so that the device may place asecond stitch thought the tissue in a different location than the firststitch. For example, the step of repositioning the suture passer mayinclude moving the first arm proximally relative to the long axis of thedevice. In some variations, the step of repositioning the suture passercomprises moving the first arm proximally relative to the long axis ofthe device to an intermediate stop. The step of repositioning the suturepasser may comprise moving the first arm distally relative to the longaxis of the device. In some variations, the step of repositioning thesuture passer comprises moving suture passer longitudinally relative tothe meniscus.

The second round of extending and withdrawing the tissue penetrator maybe used to pass an additional stitch through the tissue. For example,the step of extending and withdrawing the tissue penetrator across theopening between the first and second arms to pass a suture between thefirst and second arms a second time may comprise extending the tissuepenetrator having a suture shuttle attached thereto from within thefirst arm, through tissue, and engaging a shuttle dock within the secondarm, and withdrawing the tissue penetrator back into the first arm whileleaving a suture shuttle in the shuttle dock.

In any of the methods described herein, the methods may includerepeating the steps of repositioning and extending and withdrawing thetissue penetrator across the opening between the first and second armsto pass the suture between the first and second arms multiple times.

Also described herein are methods of teaching repair of torn meniscus.Methods of teaching repair of a torn meniscus may include teaching anyof the methods for repairing a torn meniscus described herein. Teachingmay include providing written instructions, oral instructions, visualinstructions, audio/visual instructions, or the like. Instructions maybe provided in electronic or non-electronic formats.

Also described herein are method of repairing a torn meniscus using acontinuous suture passer having a first arm and a second arm and adistal to proximal long axis, the method comprising: placing the distalend region of the second arm of the suture passer adjacent to thesuperior side of the meniscus, wherein the distal end region of thesecond arm is bent relative to the long axis of the suture passer;extending the distal end region of the first arm of a suture passerdistally relative to the long axis of the suture passer, to position thefirst arm under the side of the meniscus opposite the superior surface,so that the distal end regions of the first and second arms of thesuture passer form a v-shaped opening in which at least a portion of themeniscus is positioned; extending a tissue penetrator from the firstarm, in a curved path through tissue across the opening between thefirst and second arms to engage a suture shuttle held by a shuttle dockon the second arm; withdrawing the tissue penetrator back into the firstarm while drawing the suture shuttle through the tissue; repositioningthe suture passer without removing the suture passer from the meniscus;extending the tissue penetrator with the suture shuttle from the firstarm, in a curved path through tissue across the opening between thefirst and second arms to engage a suture shuttle held by a shuttle dockon the second arm; and withdrawing the tissue penetrator back into thefirst arm while leaving the suture shuttle in the shuttle dock on thesecond arm. In some variations, these methods may also include repeatingthe steps of repositioning the suture passer, extending the tissuepenetrator from the first arm, in a curved path through tissue acrossthe opening between the first and second arms to engage the sutureshuttle held by the shuttle dock, and withdrawing the tissue penetratorback into the first arm while drawing the suture shuttle through thetissue.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A shows a schematic of a portion of a torn meniscus between afemur and tibia and a suture passer to the right.

FIGS. 1B-1D illustrate insertion of the suture passer surgical deviceinto the joint and around the torn meniscus.

FIGS. 1E-1H illustrate passing the suture through the meniscus multipletimes using the suture passer as described herein.

FIGS. 1I-1M illustrate removal of the suture passer, retaining thesuture in position.

FIGS. 2A and 2B illustrate the anatomy of the meniscus.

FIG. 3 illustrates the anatomy of the meniscus, including the capsuleand associated vascular tissue.

FIG. 4 illustrates the structure of a meniscus.

FIGS. 5A-5E illustrate various tear patterns that may be repaired usingthe invention described herein.

FIG. 6A-6C illustrate meniscus repair using prior art devices.

FIG. 6D illustrates meniscus repair using a device as described herein.

FIG. 7A shows one variation of a meniscus repair suture passer asdescribed herein.

FIGS. 7B-7D illustrate various preset (e.g., ‘lock’) positions for themeniscus repair suture passer shown in FIG. 7A.

FIG. 8 shows another variation of a meniscus repair suture passer asdescribed herein.

FIG. 9A shows one variation of a meniscus repair suture passer.

FIGS. 9B and 9C show another variation of a meniscus repair suturepasser.

FIGS. 10A and 10 B illustrate one variation of a meniscus repair suturepasser.

FIGS. 10C and 10D show a meniscus repair suture passer from twodifferent side perspective views in which the upper (bent) arm extendedand the lower (straight) arm retracted.

FIGS. 10E and 10F show the meniscus repair suture passer of FIGS. 10Cand 10D after the lower (straight) arm has been extended.

FIGS. 10G and 10H show the meniscus repair suture passer of FIGS. 10Cand 10D after the lower (straight) arm has been extended and the curvedtissue penetrator has been extended.

FIG. 11A-11 i illustrate use of a meniscus repair suture passerrepairing a radial tear in a meniscus.

FIGS. 12A and 12B illustrate exemplary dimensions and interaction of thefirst and second (lower and upper) arms and a tissue penetrator when thefirst arm is fully (FIG. 12A) and partially (FIG. 12B) extended. Thedimensions illustrated are exemplary only, and any of the variations ofthe device shown herein may be formed having other dimensions, includingdimensions that are collectively or individually scaled to be betweenapproximately +/−25% and 200% of the values shown.

FIGS. 13A and 13B show one variation of a curved tissue penetrator in arelaxed and curved (FIG. 13A) and a straightened (FIG. 13B)configuration.

FIGS. 14A and 14B illustrate the curved tissue penetrator of FIGS. 13Aand 13B retracted into the lower arm/jaw (FIG. 14A) and extending fromthe lower arm/jaw (FIG. 14B) to pass a suture shuttle from the lower tothe upper arm/jaw.

FIG. 14C illustrates another variation of a curved or curvable tissuepenetrator.

FIGS. 15A and 15B illustrate one embodiment of a suture shuttle.

FIGS. 16A and 16B illustrate another embodiment of the suture shuttle.

FIG. 17 illustrates yet another embodiment of the suture shuttle.

FIG. 18 illustrates one embodiment of a tissue penetrator.

FIGS. 19A-19D illustrate one embodiment of the interaction between thesuture shuttle and the tissue penetrator.

FIG. 20 illustrates a first embodiment of a suture clip.

FIG. 21A shows one variation of a tissue-penetrating suture shuttle(with a connected suture) connected/coupled to a tissue penetratingelement.

FIG. 21B shows the tissue penetrating suture shuttle of FIG. 21Aseparated from the tissue penetrating element.

FIG. 21C shows an enlarged view of the distal tip region of the tissuepenetrating element shown in FIG. 21A.

FIGS. 22A-22B show another variation of a tissue penetrating sutureshuttle and tissue penetrator, in side perspective views. FIG. 22B showsthe distal tissue penetrating suture shuttle separated from the tissuepenetrating element of the device.

FIG. 23 illustrates a section though a knee indicating one method ofapproach for repairing a meniscus as described herein.

FIGS. 24A to 24C illustrate one method of positioning a meniscus repairsuture passer around the meniscus.

DETAILED DESCRIPTION OF THE INVENTION

Described herein are suture passers for meniscus repair. In general,these devices may be referred to herein as meniscus repair suturepassers, meniscus repair devices, or simply suture passers. The devicesdescribed herein may be configured to repair a meniscus (knee jointmeniscus), and may have two arms which extend longitudinally and can beexpanded around a meniscus from a lateral (central) approach. Typically,the distal end region (e.g., the distal-most 3 or less cm) of one of thearms is bent or bendable at an angle away from the long axis of thedevice, and the other arm is axially movable distally and proximally (inthe direction of the long axis of the device). Extending the distallyand proximally movable arm distally will form an acute angled opening atthe distal end that can be positioned around the meniscus, and a suturecan be passed from one arm to the other through the meniscus or adjacenttissues to repair meniscal tears. The suture may be passed back andforth through the tissue multiple times by using a tissue penetratorthat can extend and retract from just one of the arms to move a sutureshuttle between the two arms.

Thus, the meniscus repair suture passer devices described herein maypass a suture two or more times through the meniscus so that the suturepasses over the top and bottom of the meniscus. The angle and/orposition of the device may be adjusted as necessary before and duringthe procedure, including between passing the suture through variousportions of the meniscus. Thus, the meniscus repair suture passersdescribe herein are adapted for percutaneous use.

In general, a system including a suture passer as described herein mayinclude a first arm, a second arm, a suture-passing tissue penetratingelement (e.g., needle), a shuttle for passing a suture, and one or moreshuttle seats for releasably retaining and releasing the suture shuttle.In some variations the tissue penetrating element is a curved needleelement that is configured to extend from the first or second arm (fromwhich it may be extended and retracted), through tissue (or air), andapproach the second or first arm, where it may engage or disengage(alternately or cyclically) a suture shuttle held in a shuttle seat. Insome variations, the first arm of the suture passer may be configuredfor axial movement (e.g., forward and backwards along the long axis ofthe device). The suture passer may be configured so that the first armincludes two or more stops. For example, the first arm may include afirst stop in which the first arm is fully retracted axially, so thatthe first arm is retraced proximally while the second arm extendsdistally, and a second stop (extended stop) when the first arm is fullyextended distally so that the tissue penetrating element (e.g., needle)may be extended from the first arm to engage a shuttle seat on thesecond arm. In some variations the suture passer includes a third ormore (e.g., intermediate) stop(s) in which the first arm is partiallyextended distally at a position where the tissue penetrating element maybe extended from the first arm to engage a second shuttle seat on thesecond arm. This is illustrated in FIGS. 7B-7D, described below.

One or more arms of the suture passer may be bent or curved. Forexample, the second arm of the device may be bent, curved, or angled(e.g., “upwards” away from the first arm, or from the long axis of thedevice, including the first arm) so that the ends region of the secondarm (the upper arm) relative to the long axis is bent at approximatelythe angle of the meniscus (e.g., the superior face of the meniscus). Theangle may be fixed (e.g., at an acute angle of approximately 10°, 15°,20°, 25°, 25°, 30°, 35°, 40°, 45°, 60°, etc. including any angle between1° and 90°). For example, the angle may be between 20 degrees and 50degrees. In some variations, the angle between the first and second armsis variable (e.g., either or both arms may be bent or adjusted to adjustthe angle therebetween). The angle of the bend in the upper (second) armmay be approximately the average angle between the superior and inferiorfaces of the meniscus; for example, the angle may be approximately 35degrees+/−2 degrees, 5 degrees, 7 degrees, 10 degrees, 15 degrees, etc.In general the bend forms an acute angle with the lower (second) armwhen the second arm is extended distally. In some variations, asmentioned, the distal end region of the second arm may be bendable froma straight or pre-bent configuration into the final bend configuration.

As mentioned, the second arm may include one or more shuttle seats. Ingeneral, the shuttle seats may be configured to releasably engage asuture shuttle to which the suture can be connected. The suture shuttleis thereby passed between the shuttle seat on the second arm and thetissue penetrating element that may extend and retract into the firstarm. The suture shuttle and tissue penetrating element may be configuredas described in the descriptions previously incorporated by reference(e.g., U.S. Ser. No. 11/773,388 and U.S. Ser. No. 12/291,159). Forexample, the shuttle may be a clip (e.g., a triangular-shaped clip) towhich a suture is secured; the clip may be configured to snap on an offof the tissue penetrating element (e.g., a curved needle having atriangular cross-section). In some variations, the suture shuttle with asuture attached is pre-loaded into the distal-most shuttle seat on thefirst arm of the device. FIGS. 15A-22B, described in more detail below,illustrate some variations of suture shuttles and attachment regions tovarious tissue penetrators.

A tissue penetrating element may be a curved member that retracts orextends from one of the arms. In particular, a tissue penetrating membermay be a curved or curvable element that retracts completely into ahousing in the distal end region of the first arm, and extends outwardsin a curved pathway. In some variations, the tissue penetrator may beconfigured to extend from the distal end region of the second arm, andto retract fully into the body of the second arm; in some variations aportion of the tissue penetrating member may extend from the first armeven when fully retracted into the first arm. The second arm or otherportions of the suture passer may be configured to include a track orpathway for the tissue penetrating member so that the tissue penetratingmember does not prevent the first arm from extending or retractingaxially relative to the body of the device.

FIGS. 1A-1M show one variation of a suture passer used to repair a tornmeniscus. These figures illustrate the operation of the device to repaira peripheral vertical tear in a meniscus.

For example, FIG. 1A shows a sagittal cross-section through a patient'sknee. A portion of the meniscus is shown. The vertical tear 101 (shownas a line) in the peripheral region of the meniscus 100 is illustrated.The femur is shown above the tibia, with the torn edge of the meniscusbetween the two. One variation of a continuous suture passer 103 isshown to the right of the cross-section through the knee. The suturepasser may be inserted into the joint via an arthroscopic or an open (orsemi-open) surgical procedure. For example, in some variations the tornmeniscus may be accessed and visualized arthroscopically; the suturepasser may be inserted through a separate incision or through the sameincision.

In this example, the suture passer is inserted in a collapsed orretracted configuration, in which the first arm 105 is retractedproximally (e.g., towards a handle or control at the proximal end). Thesecond arm 107 extends from the distal end (and may be fixed in thisextended position, or it may be adjustable or extendable). The secondarm 107 shown in this configuration is curved (‘upwards’) so that it canbe inserted around the torn meniscus, as shown in FIGS. 1B-1C. Theentire suture passer is sized for use in this space. For example, thesuture passer may have a diameter in the un-extended/deliveryconfiguration that is less than a typical (or size-appropriate) spacebetween the femur and tibia, i.e., less than about 10 mm, less thanabout 9 mm, less than about 8 mm, less than about 7 mm, less than about6 mm, etc. This diameter may include the diameter of the first arm,which may have an individual diameter of less than about 5 mm, less thanabout 4 mm, less than about 3 mm, less than about 2 mm, etc.

The distal end of the suture passer, formed by the distal end region ofthe second arm, may thus be extended into the tissue and above the tornmeniscus, as illustrated in FIGS. 1A-1C. Once the second (upper) arm ispositioned, the first (lower) arm 105 may be extended from the device,as illustrated in FIG. 1D. In this example, the first arm is extendedfrom the proximal region of the device, so that it may extend under themeniscus, opposite from the second arm. The first arm may be straight(as shown in FIGS. 1A-1K), or it may be curved or bendable.

In the illustrated method of FIGS. 1A-1K, the first, lower, arm isextendable axially from the body of the device. The lower arm extendsforward by sliding underneath the inferior surface of the meniscus andtowards the capsule of the underside of the meniscus. The lower arm maybe extended to the most distal “stop.” The distal stop may be indicatedby a resistance (e.g. a physical stop), and may be locking. For example,the second arm may click into position when held in a stop on the suturepasser. A handle or control on the device may be used to disengage andwithdraw the device.

Once the first arm is in the desired axial position (e.g., fullyextended or otherwise) relative to the first arm, the suture may bepassed. For example, FIG. 1E illustrates the initial step of extendingthe tissue penetrating element (needle) 111 from within the first armand across the space separating the first and second arms. In thisvariation, the tissue penetrating element is a curved needle that ispushed from the distal end region of the device as illustrated to passthrough the meniscus as shown. Initially, the tissue penetrating memberjust forms a pathway through the tissue; the shuttle and suture are heldwithin the second arm. In this example, the needle penetrates throughthe peripheral menisocapsular tissue and mates with a complementaryregion of the second arm, the first distal shuttle seat. The shuttle andan attached suture are initially pre-loaded into the distal shuttleseat. Contacting the shuttle seat with the tissue penetrating memberwhen the shuttle is already held in the shuttle seat may cause theshuttle to snap onto tissue penetrating member, and release the shuttlefrom the seat, as illustrated in FIG. 1E. Thereafter, the shuttle andany attached suture 113 may be withdrawn back through the meniscus onthe tissue penetrating member as it is retracted into the second arm, asillustrated in FIG. 1F. The suture is thereby drawn across and throughthe meniscus.

In some variations the device is configured so that the tissuepenetrating element (e.g., needle, etc.) may be extended only when thelower arm is extended to a position from which the tissue penetratingelement may mate with the receiving site (e.g., shuttle seat) on theopposite arm.

In FIG. 1G, the first (lower) arm 105 can then be retracted slightly. Inany of these variations, the arms may be referred to as forming a “jaw”and thus the second arm may be referred to as the upper or second jawand the first arm may be referred to as the first or lower jaw. In thisexample, the first arm is retracted into a stop position that is locatedproximal to the distal end. This second stop may be referred to as theintermediate or second stop position (the distal end position is thefirst or distal stop, and the fully retracted position may be referredto as the proximal stop position). The device may hold or releasably“lock” the first arm in this position so that the tissue penetratingmember (to which the shuttle is now attached) may be extended backthrough the meniscus, in a region located more peripheral to the tear,as illustrated in FIGS. 1G and 1H. Meanwhile, the upper (second) arm isleft securely in place. In some variation (e.g., anatomy permitting),the second arm may also be slightly withdrawn proximally, or the entiredevice may be moved laterally or proximally to position an additionalstitch at a different position.

In some of the variations described herein, the lower arm (e.g., the armincluding the tissue penetrating element) may be longitudinallyextended/retracted relative to the rest of the device. In somevariations the upper arm may be extended/retracted relative to the restof the device. This is illustrated below in the variations shown inFIGS. 9-10B.

Returning now to FIG. 1H, the tissue penetrating member with attachedshuttle and suture is again extended, this time penetrating on theopposite side of the tear from the previous stitch, so that the tear maybe stitched closed. The needle is passed until it engages (distally)with a second shuttle seat region of the second arm; when this occursthe shuttle is held securing in the shuttle seat and is uncoupled (e.g.,unclipped, or removed) from the tissue penetrating element, so that thetissue penetrating element can be withdrawn to leave the shuttle behindin the shuttle seat on the second arm, as illustrated in FIG. 1I. Insome variations the suture passer may be moved slightly (e.g., laterallyout of the plane of the cross-section shown) to again pass the suture byrepeating some of the steps above, e.g., from FIG. 1E forwards, or itmay be removed.

In FIG. 1J, the first arm (and thus the device) is withdrawn axially(proximally), so that the device may be removed, as shown in FIG. 1K.Removing the device leaves the suture passed through the meniscus, asillustrated in FIG. 1L. The suture may be drawn through the tissue,leaving the loop through the tissue behind. A knot may then be tied orthe suture may otherwise be secured, as illustrated in FIG. 1M. Apre-tied knot may be pre-packaged to slide into place as the device iswithdrawn.

FIG. 6D illustrates one variation of a suture made through a region ofthe meniscus having a longitudinal tear. The resulting suture may becompared with other types of suture fixations (“stitches”) made by otherdevices, as discussed in the background section above, relative to FIGS.6A-6C. In comparison, the meniscus suture devices described herein maypass a suture through the meniscus near the boundary (or just past theboundary) of the capsule region (to the right of the figure in FIG. 6D).Because the device may pass the suture vertically through the meniscus(as illustrated in FIGS. 1A-1M), and because of the orientation andconfiguration of the tissue penetrating element, the suture may bepassed without risk of plunging deep into and beyond the capsule regionof the knee. This design may prevent injury to nearby nerves andvascular tissues (e.g., blood vessels). In addition, the suture may bepassed over and around the outside regions of the capsule, asillustrated.

FIG. 7A illustrates one variation of a meniscus repair suture passer. Inthis example, the suture passer includes an upper (“second”) jaw or armthat extends longitudinally from the elongate body and curves up (out ofthe longitudinal axis) as illustrated. The lower “jaw” or arm (firstarm) member is slideable relative to the upper arm, and can be extendedin the longitudinal axis of the device and held in any of threepositions, as illustrated in FIGS. 7B-7D. These positions are labeled“1^(st) position,” in which the lower arm is fully retracted, as shownin FIG. 7B. A control, slider member (shown as a finger or thumb sliderin FIG. 7A), may be used to axially move (e.g., slide) the lower armforward or back (or to hold the lower arm stable while moving the restof the device forward/back relative to the lower arm). The secondposition, shown in FIG. 7C is fully extended. As mentioned, the devicemay include a lock or bias to hold the arms in this position once slidor otherwise moved here. For example, the device may include aspring-lock that can be engaged (releasably) to hold it in position,allowing the tissue penetrator to be extended or retracted as describedabove. Finally, FIG. 7D illustrates a third, intermediate, position ofthe first arm, which may also be locked, and for which a correspondingmating site (e.g., docking site) for the tissue penetrating element mayalso be present. The intermediate position (3^(rd) position) may beoptional. In some variations additional intermediate positions may alsobe included.

A separate mechanism may be used to extend/retract the tissuepenetrating element from the lower arm to engage the upper arm. Forexample, a trigger may be included. In FIG. 7A and FIG. 8, the deviceincludes a push element 701 within the cannula of the elongate body thatallows the tissue penetrating element to be extended/retracted. Asmentioned the device may be configured to prevent the tissue penetratingelement from extending (or retracting) when the arms forming the openingare not aligned so that tissue penetrating element will not extendunless it can engage a shuttle dock region (and couple with/release thesuture shuttle and/or suture). For example, the tissue penetrator may beallowed to extend from the device only when the lower arm is in thesecond or third positions.

The shuttle dock region may be configured to alternatively lock (hold)and release the suture shuttle, depending on whether the suture shuttleis already present within the dock. This may allow the suture (andshuttle) to be released or retained by dock/tissue penetrator and pulledthrough the tissue alternatively, allowing continuous suturing.

In some variations, the upper or lower arm is removable or replaceable.For example, the device may be modular. FIGS. 9A and 9B illustratesvariations of meniscus suture passer devices having a modular designallowing various upper arms to be connected to the rest of the device,as shown in FIG. 9C. In this example, the principles of which may begeneralized to other variations (e.g., in which the lower arm isreplaceable), the upper arm may be pre-loaded with a suture (which maybe coupled to a shuttle). Different, interchangeable, upper arms may beused that include different structures. For example, different upperarms may have different bend angles of the arm relative to the long axisof the device (e.g., between 10 and 60 degrees, as indicated above). Insome variations the device may have different lengths, widths, and/orthicknesses. In some variations different upper arms may be selectedbased on the number and/or locations of the shuttle docks on the arm.Although this section refers to the jaw or arms as the modular orinterchangeable feature of the device, the actual interchangeable regionmay include the bent distal end region of the upper arm and the un-bentelongate portion, as seen in FIGS. 9A and 9B. In this example, theinterchangeable region 902 also includes a grip region 905 that may beused to couple the second arm to the rest of the device, and may beuseful in variations in which the upper arm (second arm) is axiallymovable relative to the handle. FIGS. 9B and 9C illustrate thisvariation in slightly more detail, showing the disposable and preloadedupper arm 902 and a potentially re-usable or durable lower arm that maybe combined to form the meniscus suture passer device 900 shown in FIG.9C. The durable portion may be sterilizable so that it can be re-usedwith multiple patients, or it may be merely used to pass multiplesutures for a single patient.

In operation, a user may measure or probe the meniscus region (includingnon-invasive imaging) to determine which upper arm to select. The upperarm may then be coupled with the rest of the device, including the lowerarm and handle. The upper arm may be coupled to the rest of the deviceby a snap-fit, a lock, and/or any other mechanical, magnetic, etc.connection means that may be used to link the upper arm with the rest ofthe device.

As mentioned above, in some variations the upper arm is held relativelystationary relative to the rest of the device (e.g., the handle,elongate body, etc.) and the lower arm is axially extended/retracted. Insome variations, including the variation shown in FIGS. 9A-9C, the upperarm is axially extendable/retractable. For example, the upper arm may beattached to the meniscus repair device and allowed to slide forward orretracted. The lower arm may also be configured to slide axially, or itmay be held fixed relative to the rest of the device (e.g., the handleregion).

FIGS. 10A and 10B illustrate another variation of a meniscus suturepasser device in which the upper and lower arms may be moved axially andindividually locked into position.

The various configuration of the upper and lower arm relative to eachother in one variation of a meniscus repair suture passer device areillustrated in FIGS. 10C to 10H. For example, FIGS. 10C and 10Dillustrate two perspective views of one variation of a meniscus repairsuture passer device 1001 having an elongate first arm 1003 that isaxially movable (in the dorsal/proximal long axis of the device 1005)relative to the rest of the device, including a second arm 1007. Theelongate second arm 1007 extends adjacent to the first arm along thelong axis 1005 of the device. The elongate second arm also includes abent distal end region 1009 that may be bent relative at an anglerelative to the long axis of the device, as shown. The distal tip ofthis distal end region is atraumatic, and is shown as substantiallyblunt. In FIGS. 10C and 10D, the first arm is retracted proximally sothat it does not form a distal opening in this position.

FIGS. 10E and 10F illustrate an extended position in which the distalend region of the first arm 1011 has been extended distally towards thedistal end region 1009 of the upper arm (second arm 1007). The distalend regions of the first and second arms 1009, 1011 have formed a distalopening between the first and second arms 1014. The exit for the tissuepenetrator is visible as an opening 1018 in the lower arm 1003 in FIG.10F. FIGS. 10G and 10H show the same views of the suture passers 1001shown in FIGS. 10E and 10F, but with the tissue penetrator 1020 extendedfrom the first (lower) arm 1003. The tissue penetrator may extend in acurved path through the tissue between the first and second arms, asshown. All of the devices shown in FIGS. 10A-10H include a handle 1030.In FIGS. 10G and 10H a control 1031 on the handle 1030 is shown asdepressed, actuating the extension of the tissue penetrator 1018 betweenthe upper and lower arms.

As described, the meniscus repair suture devices described herein may beused to repair longitudinal meniscus tears (e.g., FIG. 5A). Theconfiguration of the arms (which move axially in the long axis of thedevice) and the tissue penetrator element (which is configured to extendsubstantially perpendicular to the lower arm), of the devices describedherein may also be used to repair radial or even oblique tears in themeniscus (e.g., FIGS. 5B-5E). Repair of such tears is typicallydifficult or impossible using other prior art devices. Repair of suchradial and oblique peripheral tears is made possible because the suturepasser described herein may pass suture from the superior (upper) to theinferior (lower) surface of the meniscus (or vice versa). Repair ofradial and oblique tears is also made simpler and more convenientbecause the meniscus suture passer devices described herein maycontinuously pass a suture between the upper and lower arms withouthaving to be removed from the tissue. This is illustrated in FIGS.11A-11 i.

FIGS. 11A-11 i illustrate one variation of a method of repairing aradial meniscus tear using one variation of a meniscus repair suturepasser device as described herein. FIGS. 11A-11B shows the distal end ofa suture passer (the curved/bent distal end of the upper arm of thedevice) 1101 approaching a region of a meniscus having a radial tear1103. The distal tip of the upper arm may be maneuvered to fit within aminimal incision and may follow along the contour of the upper surfaceof the meniscus. Once the upper arm is positioned, the lower arm 1105may be extended under the meniscus, as shown in FIG. 11C. In thisexample, the lower arm is fully extended, and then the tissuepenetrating element is extended through the tissue. The tissuepenetrator may extend through the meniscus and/or through the capsuleregion. In this example, the lower arm is pre-loaded with a sutureattached to a shuttle and held on the tissue penetrator. In somevariations the upper arm is pre-loaded, with the suture and shuttle heldin a shuttle receiver/dock at the distal end region of the upper arm. InFIG. 11C, extending the tissue penetrator until it engages with theshuttle in the shuttle dock on the upper arm causes the shuttle tosecure onto the tissue penetrator and be released from the shuttle dock.Any appropriate tissue penetrator may be used. For example, the tissuepenetrator may be a solid curved needle-like element having a triangularcross-section that engages with the inside of a shuttle “clip” connectedto the suture. In this example, the suture and shuttle are initiallyheld on the tissue penetrator (clipped on) and the suture is pulledthrough the tissue as the tissue penetrator is extended through thetissue. Once the tissue penetrator engages the shuttle receiver/dock onthe upper arm, it may engage the shuttle receiver and toggle thedock/receiver to secure the shuttle within the receiver, allowing it tobe unclipped from the tissue penetrator.

In general, engagement of the tissue penetrator with the shuttle regionmay toggle engagement or release of the shuttle dock/receiver from theupper arm. This toggling may allow the upper arm to hold or release theshuttle from the dock/receiver; toggling may therefore pre-set thedock/receiver it to either release or receive the shuttle during thenext engagement with the tissue penetrator. Thus, the shuttledock/receiver may have a mechanical “memory.” Alternatively, the shuttledock may be configured so that if it already has the shuttle present itwill release it, and if it does not have the shuttle it will capture itfrom the tissue penetrator. This toggling may be individually controlledfor all of the shuttle docks on the upper arm if more than one ispresent), or it may be collectively controlled. Thus, in some variationseach of the shuttle docks may be loaded with a separate suture, allowingmultiple sutures to be passed without having to remove and re-load thedevice, by using separate shuttle docks/receivers on the upper arm.

Once the suture is passed from the lower arm (via the tissue penetrator)to the upper arm, the tissue penetrator may be retracted back the lowerarm, leaving the shuttle and suture in the upper arm, and the device maybe moved laterally relative to the meniscus, as shown in FIG. 11D.Lateral motion of the distal end of the device across the radial tear,as illustrated, will pull the suture from the lower arm (e.g., where itmay be held loosely within a lumen of the device (e.g., in the lower armor a cannulated region of the device body) and through the tissue tofollow the upper arm. The suture remains attached to the suture shuttle,and therefore follows it as the arms are moved relative to the tissue.The dashed lines show the path of the ends of the device in FIG. 11D.

Generally, the suture may be managed by the device. The suture may beheld loosely within a lumen of the device (e.g., within the upper arm,elongate body region of the device, lower arm, etc.) so that it may befed out of the device and allowed to pass through the tissue easily. Inother variations the suture is not held within the device, but it eitherfreely connected (e.g., hanging from the distal end of the device),partially held within the device, fed through a loop of wire or suturefrom the device, or kept in a track or guide along the outside of thedevice (or some combination thereof). In FIG. 11E, the suture is shownextending from the elongate body of the device. In other variations thesuture may be held in the upper arm, particularly when preloaded in theupper arm. The device (including the upper arm, elongate body, lowerarm, etc.) may include one or more lumen or passages for the suture,which may include exits (e.g., side exits) for managing the pathway ofthe suture as it is passed through the tissue.

Returning to FIG. 11D, once the distal end of the device has beenpositioned on the other side of the meniscus tear, the tissuepenetrating member may again be extended through the tissue (e.g.,through the meniscus, capsule, etc.) where it can again engage with theshuttle and/or suture, causing the shuttle to be disengaged from theshuttle dock/receiver on the upper arm. The shuttle and suture are thencoupled to the tissue penetrator (e.g., by snapping the shuttle onto thetissue penetrator) and the tissue penetrator can be pulled through thetissue, pulling the suture with it though the tissue until the shuttleand suture coupled to the tissue penetrator are withdrawn into the lowerarm, allowing it to be withdrawn, as shown in FIG. 11E.

The resulting suture passes through the meniscus on either side of thetear, and the suture extends across the tear, in the mattress-likestitch shown in FIG. 11E. Thereafter, the device can be withdrawn,leaving the ends of the suture trailing, as illustrated in FIG. 11F,allowing the suture ends to be tied across the tear, pulling the side ofthe torn region of meniscus together, as illustrated in FIG. 11G. Thesuture may be knotted (directly or using a knotting device), and tiedoff. Alternatively, a prettied sliding knot may be provided within thedevice. Thereafter, the less-vascular regions of meniscus (towards thenarrower, more apical region) may be removed, as illustrated in FIGS.11H and 11 i.

In general, the distal end regions of the lower and upper (first andsecond) arms may be configured to form a distal opening by sliding thelower (first) arm distally once the upper (second) arm has beenpositioned on one side, preferably the superior side, of the meniscus.The distal end regions may also be configured so that the tissuepenetrator may be able to extend across the tissue within the distalopening from one or more positions. For example, one schematicillustration of a distal opening formed by the distal ends of the firstand second arms of a suture passer is illustrated in FIGS. 12A and 12B.These examples indicate exemplary dimensions; these dimensions areintended only to provide one illustration of dimensions that may beused. The suture passer devices making up this invention are not limitedto these dimensions.

For example, FIG. 12A shows a lower arm 1205 that is axially movablerelative to the upper arm 1205. A tissue penetrator 1207 may be housedwithin the lower arm completely until it is extended across the distalopening 1211. In this example, the angle between the upper and lowerarms (θ) is approximately 35 degrees. As mentioned above this angle maybe greater or lesser than 35 degrees by 2 degrees, 5 degrees, 10degrees, etc. but is generally an acute angle slightly greater than thecorresponding angle between the inferior and superior surfaces of mostof menisci. In this example, the overall diameter of the shaft region(proximal to the distal end region forming the distal opening) isapproximately 6 mm. In general, this diameter may be less than 10-15 mm.In FIG. 12A, the tissue penetrator extends near the distal ends of thefirst and second arms, so that the tissue penetrator exist the distalend of the lower (first) arm 1205 and travels in a curved path acrossthe distal opening to pass at least partially into the shuttle dockregion (not visible) near the distal end of the upper (second) arm 1203.In FIG. 12B, the lower (first) arm 1205 is retracted partially in theproximal direction. In this configuration, the tissue penetrator 1207may be extended across the distal opening 1211′ to engage with a shuttledock (not visible) on the upper (second) arm 1203. Thus, as describedabove, by moving the lower arm, the device may make radially differentpathways (and thus suture stitches) through the meniscus, withoutrequiring the device to otherwise move. In this example, moving thelower arm may be considered one way to reposition the device relative tothe meniscus. In FIGS. 12A and 13B, the shaft diameter is approximately6 mm, the distal opening from top to bottom is approximately 12 mm, andthe tissue penetration at the deepest point is approximately 7 mm, asillustrated on the figures.

In general, the tissue penetrators described may be completely retractedwithin one of the arms, typically the distal end region of the firstarm. In some variations, the needle may be curved. In other variationsit may be desirable to have the needle assume a curved shape uponleaving the arm. For example, the needle may be pre-biased or bendableinto a curve that permits it to extend across the distal opening formedbetween the arms in a curve. FIGS. 13A and 13B illustrate one variationof a curved needle (FIG. 13A) that may straighten out when retractedinto the arm, as shown in FIG. 13B. In this example, the needle includesslices 1303 that increase the flexibility of the needle. One side of theneedle is solid 1305, so that the needle retains lateral stability. Theneedle may be formed of a metal (e.g., stainless steel, shape memoryalloys such as Nitinol, etc.). FIGS. 14A and 14B illustrate onevariation of a needle such as the one shown in FIGS. 13A and 13Bretracted into (FIG. 14A) and extending from (FIG. 14B) a lower arm toextend across to the arm forming a distal opening. An axial pushingelement (not shown) may be attached to the proximal (non-sharp) end ofthe tissue penetrator needle to drive it in and out of the lower arm.

FIG. 14C illustrates another variation of a needle that is bendable orcurveable. In this example, the needle is hinged 1403. The pivot pointallows the needle to be collapsed for retraction into the lower law.Multiple hinged regions may be used. In some variations, the needle maybe solid, but may be formed of a shape memory or super/hyper elasticmaterial that assumes the curved shape upon leaving the lower arm.

Any appropriate variation of tissue penetrator and suture shuttle may beused, as mentioned above. FIGS. 15A-20 illustrate some variations ofsuture shuttles and tissue penetrators. For example, FIGS. 15A-17illustrate various embodiments of suture shuttle 70, 170 and 270. Asuture shuttle 70, 170 and 270 may be any shape such that it may bereleasably attached to tissue penetrator 50. While the shape of shuttle70, 170 and 270 may correspond to the shape of at least a portion of thetissue penetrator 50 for attachment purposes, it may be of any suitableshape. In these illustrative examples, the shuttle is generallytriangular in shape, which may correspond to a tissue penetrator 50having a generally triangular cross-sectional shape. The illustratedexamples of suture shuttles are “channel shuttles” which may engage atissue penetrator 50. For example, a triangular or cylindrical tissuepenetrator 50 may be used, as illustrated in FIGS. 18-19D, to which thesuture shuttle 70, 170 and 270 is adapted to connect. Tissue penetrator50 may be, for example, a needle or any like instrument capable ofpuncturing through tissue. Shuttle 70, 170 and 270 may be substantiallyhollow within the triangular shape, and may further have a channel 71,171 and 271, or opening, along a portion of the triangular body. Thischannel 71, 171 or 271 may serve as an entry way for tissue penetrator50 to engage the shuttle 70, 170 and 270. Thus, in these embodiments,the shuttle 70, 170 and 270 wraps around a portion of the tissuepenetrator 50, which is positioned within the body of the shuttle.

For example, in FIGS. 15A-B, the channel 71 may be positioned on anyportion of the shuttle 70. In the illustrated examples, the channel ispositioned along an apex of the triangular shape. However, a channel mayalso be placed along a side of triangular shape or in any otherappropriate place.

Some embodiments of shuttle 170, 270 may also contain openings 74 whichmay make the shuttle lighter, and may also facilitate flexing of theshuttle so that it can readily attach/detach from the tissue penetrator50. Further, opening 74 may provide an area through which a retainingmechanism, such as a retainer pin 30, may pass to secure shuttle 170,270.

Some embodiments of shuttle 70, 170 of the present invention may includeadditional features which may provide controllable, positive, robust,repeatable, and manufacturable retaining structures. Such features mayinclude, for example, protrusions, such as dimples 72, 172 or the like,and finger springs 175 a and b, both of which may help to retain shuttle170 on the tissue penetrator 50.

The protruding dimples 72, 172 may interact with divots 52, 152 locatedwithin a cut-out 51, 151, or recessed portion, of the tissue penetrator50. The dimples 72, 172 allow for controllable, repeatable retaining ofthe shuttle 70, 170 on the tissue penetrator 50, whereby the shuttlemay, in a preferred embodiment, snap on and off the tissue penetratorrepeatedly, as necessary. In a preferred embodiment, the position ofshuttle 70, 170 on the tissue penetrator 50 may be the same given anadditional feature such as the dimples and divots. In an alternativeembodiment, dimples 72, 172 may be located on the tissue penetrator 50,while the divots 52, 152 may be located on the suture shuttle 70, 170.

In a further embodiment, the cut-out 51, in FIGS. 18-19D, may beconfigured to seat the shuttle against the outer surface of the tissuepenetrator, thereby allowing the tissue penetrator to present a uniformouter surface as it penetrates the tissue; meaning the shuttle does not“stick out” from the tissue penetrator, but is flush with the outersurface of the tissue penetrator. This helps keep the shuttle on thetissue penetrator as it extends from upper arm 20 and penetrates tissue.

Additionally, in yet a further embodiment, the upper edge 54 of tissuepenetrator 50 may be sharpened to provide additional cutting surface ontissue penetrator. In this variation, the shuttle 70 should not interactwith the upper edge 54 such that upper edge 54 is exposed to assist inthe piercing action of tissue penetrator.

In a further preferred embodiment, tissue penetrator 50 may include anadditional cut-out 51′ along a portion of tissue penetrator 50 withincut-out 51. Cut-out 51′ may allow additional room for a linkage 85.Cut-out 51′ may reduce the chance of damage to linkage 85 during tissuepenetrator 50 insertion into shuttle 70, since cut-out 51′ may provideadditional clearance for linkage 85.

In one embodiment, for example in FIGS. 16A-B and 19A-D, finger springs175 a and 175 b may interact with a ramp 153 within the cut-out 151 ofthe tissue penetrator 150. The finger springs, and even the entire sidesof the shuttle 170, may be sloped inwardly towards one end of theshuttle. Thus, in this embodiment, the finger springs are located at thenarrowest portion of the shuttle. This slope of the finger springs mayinteract with the slope of the ramp 153 of the cut-out portion 151. Theinteraction of these two slopes may regulate the holding force of theshuttle 170 on the tissue penetrator 150 prior to the dimples 172interacting with the divots 152 to firmly secure the shuttle to thetissue penetrator. Likewise, the holding force is regulated as theshuttle is removed from the tissue penetrator in a similar manner. Thus,when a force is applied to shuttle 170 to pull shuttle 170 off tissuepenetrator 150, the finger springs may be forced along the ramp, towardsthe tip of tissue penetrator, to engage the ramp, causing the fingersprings, and thus the sides of the shuttle, to flex apart from oneanother, and disengage the dimples from the divots.

Continuing with this embodiment, in FIG. 19A, for example, the dimple172 of the shuttle is engaged with the divot 152 on the tissuepenetrator 150. At this point, the finger springs may only be slightlyengaged to the tissue penetrator. FIG. 19B illustrates the shuttle 170beginning to be removed from tissue penetrator. The dimple is no longerin the divot and is instead moving along the surface of the tissuepenetrator. The finger springs 175 a are increasingly engaged onto thetissue penetrator as they move along ramp 153 within cut-out on tissuepenetrator. In FIG. 19C, the finger springs are shown as fully engagedwith tissue penetrator, particularly at the point where the ramp ends(at the distal end of cut-out portion). This full engagement may, in apreferred embodiment, cause the shuttle to flex, and as a result widen,such that the dimples are no longer in contact with the cut-out portionof the tissue penetrator. FIG. 19D illustrates the final step whereinthe dimple and finger spring are no longer touching the tissuepenetrator at all, and the tissue penetrator may be retracted, leavingthe shuttle 170 free.

Thus, in various embodiments, the tissue penetrator may be adapted tomate with one or more elements on the suture shuttle, whether it is adimple, or like protrusion, or finger springs, or the like, that canengage with a divot, depression, cut-out or ramp portion on the tissuepenetrator.

Shuttle 70, 170 and 270 may be made of any material suitable for use insurgical applications. In a preferred embodiment, the shuttle must havestrength, yet also have sufficient flexibility and resiliency to be ableto move on and off the tissue penetrator. Such movement requires theshuttle to flex during removal from and addition to the tissuepenetrator. Thus, a suitable spring characteristic may be achieved witha high stiffness material, such as steel, by designing the spring suchthat it has a high preload characteristic when installed relative to thetolerances. For example, one shuttle design illustrated herein mayinclude retention features that are lower spring stiffness & highpreload, which may help provide more consistent performance and decreasesensitivity to tolerances. Note that the intrinsic stiffness of thematerial (Young's modulus) and the spring constant of the shuttle may berelated, but may not be equivalent. In addition, these shuttle designsmay have significantly reduced tolerance sensitivity, wherein thetolerance is a small percentage of deflection, compared to other shuttledesigns. One suitable material may be stainless steel. For example, theshuttle may be composed of 0.004 in. (0.01 mm) thick 17-7 PH stainlesssteel, Condition CH-900.

Shuttle 70 may be made of material whose hardness is matched to thetissue penetrator 50. Tissue penetrators of a material that is too hardrelative to the shuttle may wear out the shuttle. In one example, thetissue penetrator is stainless steel, Rockwell 60 C hardness. Theshuttle then may be precipitation hardened stainless steel, “17-4 PH”,which is also known as stainless steel grade 630. The shape of theshuttle is matched to the shape of the tissue penetrator, and theshuttle clips onto a portion of the tissue penetrator, and can beslipped on and off repeatedly.

The shuttle 70 may be made of a material having a hardness, stiffnessand elasticity sufficient so that it may partially elastically deflectto clamp onto the tissue penetrator 50. In particular, we have foundthat matching the hardness of the shuttle to the hardness of the tissuepenetrator may be particularly important for repeated use. For example,the shuttle may be made of Nitinol, beryllium copper, copper, stainlesssteel, and alloys of stainless steel (e.g., precipitation hardenedstainless steel such as 17-7 PH stainless steel), cermet (ceramic andmetal), various polymers, or other biocompatible materials. The materialchosen may be matched to the material of the tissue penetrator forvarious properties including, for example, hardness and the like. Theshuttles may be formed in any appropriate manner, including punching,progressive die, CNC, photolithography, molding, etc.

In the above examples, a pull-out force, or the force required to removethe shuttle 70 from the tissue penetrator 50, may be more than about 2pounds of force. Preferably, the force may be about 2 to about 5 pounds.The force may be from, for example, the pulling of a suture, or sutureclip or connector, attached through one of the bore holes 73 located onshuttle 70. This force should be from the direction of about the tip ofthe tissue penetrator.

In a preferred embodiment, illustrated in FIGS. 15A-B, the bore holes 73are located away from channel 71 and towards the base of the triangle,which may be in a fold in the shuttle, as shown in FIG. 5B. In the otherillustrated embodiments, FIGS. 6A-7 for example, the bore holes 173 areadjacent the channel. FIGS. 15A-B illustrate a position of bore holes 73which may reduce, or even eliminate, the bending forces on the sides ofshuttle 70, when suture, or the like, applies a force at bore holes 73.Typically, when bore holes 73 are located adjacent channel, as in FIG.6A, the bending force on the side of the shuttle may peel the shuttlefrom the tissue penetrator 50 at a force lower than the desired removalforce, due to the advantage of the force being applied to a corner ofthe shuttle 70. However, bore holes 73 located as shown in FIG. 5Blimits this bending force, or torque, and thus prevents removal ofshuttle 70 from tissue penetrator 50 at a premature time and at a forceless than is desired for removal of shuttle 70.

In another embodiment, the shuttle 70 may be in the shape of a spiraledwire, or the like, such as a “finger torture” type device, whereby asthe shuttle is pulled by the tissue penetrator 50, the shuttle maytighten around, thereby securing itself to the tissue penetrator. Thestronger the force of the pull, the tighter the spiraled wire secures tothe tissue penetrator. When the shuttle is to be transferred from thetissue penetrator, for example, to the shuttle retainer seat 25, theshuttle may be twisted, or the like, to “unlock” the shuttle from thetissue penetrator.

Other examples of shuttles 70, which may be able to clamp onto thetissue penetrator to secure itself, may be torsion springs, snap rings,a portion of wire, elastically deformable shapes, conically taperedshapes, and the like. Elastically deformable shapes may be any shapedesired, such that it can be deformed to wrap around at least a portionof the tissue penetrator. Useful shapes may include, but are not limitedto, cylinders, triangles, overlapping rings, and any partial portion ofa shape such as a semi-circle. Once the tissue penetrator is inposition, the shape of the tissue penetrator receiving area allows theelastically deformable shape to return to its original configurationwhile being securely attached to the tissue penetrator. Of course, thecut-out 51, or recess, or receiving area, on the tissue penetrator mayin a preferred embodiment be shaped such that it coincides with theshape of the shuttle. For example, if a conically tapered shuttle wereused, the tissue penetrator may include a conically tapered cut-out on aportion of the surface. The conically tapered shuttle may be deformable,and may deform upon being moved into the cut-out. Once completely withinthe cut-out, the conically tapered shuttle would return to its originalshape and secure itself within the cut-out. The cut-out may include, forexample, a lip, or the like, to assist in securing the shuttle, fully orpartially, within the cut-out.

In other embodiments, the shuttle may constitute the tip of the tissuepenetrator 50 itself, as illustrated and described below in reference toFIGS. 21A-22B, such that the tip may be releasably coupled on the end ofthe tissue penetrator. Thus, the tip of the tissue penetrator may bepassed between distal opening formed by the distal end regions of thearms of the suture passer device, and to pass the suture (attached tothe tip), back and forth through the tissue.

Suture 90 may, in one embodiment, be attached directly to shuttle 70 atbore hole 73, or other like retention location. Of course, suture neednot be secured only by a bore hole. Instead, suture may be secured toshuttle by adhesive, a clamp, by being ties or engaged to a portion ofthe shuttle, or in any other suitable manner.

Additionally, suture 90 may be secured to shuttle 70 via an intermediarydevice, such as the examples shown in FIG. 20. One such intermediarydevice may be a suture clip, loop, or suture retainer 80. A suture clipallows for simple and efficient releasable connection of a suture to ashuttle. A suture clip may be used for continuous suture passing, oralternatively for single passing of a suture.

In operation, suture clips 80, such as the example illustrated in FIG.20, may be used as part of a system for suturing tissue, particularlywhen used with a continuous suture passer 10. For example, a suture 90may be passed from the second arm 20 to the first arm 21 and/or backfrom the first arm to the second arm of a suture passer. This may beaccomplished using an extendable tissue penetrator 50 that is connectedto the first arm, as described above. The extendable tissue penetratorcan pierce the tissue, and can also engage a suture shuttle 70, to whicha suture is attached through the suture clip 80, loop, or otherattachment. The suture may then be pulled through the passage that thetissue penetrator forms in the tissue. Extending the tissue penetratorforms a passage through the tissue, which may also pass the suturebetween the opening formed between the distal end regions of the firstand second arms. For example, the tissue penetrator may include a sutureshuttle engagement region which may be, for example, a cavity within thetissue penetrator, along the outside of the tissue penetrator, or thelike, to which the suture shuttle can be releasably attached. The suturecan be passed from the tissue penetrator in the first arm to or from asuture shuttle retainer seat 25 connected to the second arm. Thus, boththe tissue penetrator and the suture shuttle retainer seat (shuttledock) may be configured to releasably secure the suture, which may beattached to a suture shuttle.

In some variations, the suture clip 80 described herein may include anattachment linkage 85 to a suture shuttle 70, for example a tether,leash, lead wire, or the like, which may be configured to connect thesuture clip to the shuttle. In some examples, the suture clip includes abias, for example, a spring, for securing a linkage 85 within a snap-fitelement. Alternatively, the suture clip may include a central openingthrough which a linkage may be threaded. This linkage can act as aspacer. In one embodiment, the linkage may be stiffly attached to theshuttle 70 such that it both spaces the shuttle from the suture and alsocontrols the position of the shuttle based on a force exerted on thelinkage. The linkage will also control the position of the suture as theshuttle is passed from one arm to the other.

Similarly, the linkage 85 may be a stiff metallic wire, a portion ofsuture, a flexible polymeric strand, or the like. In the example of astiff metallic wire, the wire may be welded to the shuttle such that itmay project from the shuttle in a predictable manner.

In one embodiment, illustrated in FIG. 20, the shuttle 70 may beconnected to a suture clip 80 that may be a compressed loop, in whichthe compressed loop has an inner, generally “teardrop” shaped opening 86that is wider in one end than the other. The suture 90 may then bethreaded through the inner loop 86 such that it becomes wedged withinthe narrow portion of the teardrop shape. The suture may then be securedby any method known in the art such as by tying a knot or bringing theend outside of the body. The suture may also be secured solely by beingwedged within the teardrop shape, which may be sufficient to secure thesuture within the suture clip.

FIGS. 21A-22B illustrate examples of tissue penetrators in which asuture shuttle 2101 forms the distal tip of the tissue penetrator. Forexample, in FIG. 21A, the suture shuttle is an approximately three-sided(pyramidal) tissue penetrating suture shuttle that include a pointeddistal tip. This tissue penetrating suture shuttle fits over the distalend region of the tissue penetrating element, as shown in FIG. 21A. Thetissue penetrating suture shuttle is shown disengaged in FIG. 21B.

FIG. 21C shows an enlarged view of the distal tip 2105 of the tissuepenetrating element of FIGS. 21A and 21B, to which the tissuepenetrating suture shuttle (not visible in FIG. 21C) releasably secures.As is apparent in FIG. 21C, the sides of the distal tip region of thetissue penetrating element include one or more detents (projections)2107 that may snap into and engage corresponding regions within thetissue penetrating suture shuttle (not shown). Thus, even without thetissue penetrating suture shuttle, the distal end of the tissuepenetrating element in this example is also tissue-penetrating. In somevariations, the distal end is not tissue-penetrating, but may beflattened, rounded, blunted, etc. In some variations, the distal end maybe keyed to mechanically interlock with the internal portion of a tissuepenetrating suture shuttle.

In some variations, the distal end of the tissue penetrating elementincludes one or more recesses into which a projection from the tissuepenetrating suture shuttle extends.

The variation shown in FIGS. 21A-C allows the tissue penetrating sutureshuttle to snap onto the distal end of the tissue penetrating member.Friction, or the elastic deformation of one or more detents, buttons,knobs, nubs, projections, etc. may be used to hold the tissuepenetrating suture shuttle onto the tissue penetrating element. In somevariations, the tissue penetrating suture shuttle is actively secured tothe tissue penetrating element. For example, a tissue penetratingelement may include a magnetic or electromagnetic element that grasps orsecures the tissue penetrating suture shuttle to the distal end regionof the tissue penetrating element. In some variations the tissuepenetrating suture shuttle is held on the tissue penetrating element bya vacuum or other member. In some variations, a bar or other member maybe extended from the tissue penetrating element to engage with a site onor within the tissue penetrating suture shuttle to lock it in position.The lock may be deactivated or withdrawn (e.g., by withdrawing a bar) inorder to release the tissue penetrating suture shuttle form the tissuepenetrating element.

FIGS. 22A-22B illustrate another variation of a tissue penetratingsuture shuttle and tissue penetrating element. In this variation, thetissue penetrating suture shuttle includes both a pointed distal end,but also includes an elongate cutting side (the bottom surface 2205,2205′). The tissue penetrating element is also pointed at the distalend, and this end of the tissue penetrating element fits into the tissuepenetrating suture shuttle. For example, FIG. 22A shows the tissuepenetrating suture shuttle attached to the distal end of the tissuepenetrating element. FIG. 22B shows the tissue penetrating sutureshuttle disconnected from the tissue penetrating element.

In some variations the meniscus repair suture passer device isconfigured to pass a suture back and forth through tissue withoutrequiring a shuttle. For example, the tissue penetrator may beconfigured to releasably connect directly to a suture. A tissuepenetrator may include a suture engagement region (e.g., at or proximalto the distal tip of the tissue penetrator) that holds the suture untilit is released into a dock on the opposite arm of the device. Forexample, the tissue penetrator may include a hook (with or without alatch) into which the suture may be held. In some variations the tissuepenetrator includes a clamping or gasping mechanism (e.g., one or moreclamping surfaces on the tip or side of the tissue penetrator) forsecuring the suture until it can be released into the dock on theopposite arm. Similarly, the dock (which may be present on the second orupper arm in some variations), may be adapted for directly securing thesuture to the arm opposite from the arm connected to the tissuepenetrator. A suture dock may be modified from the shuttle docksillustrated above, and may include a hook, clamp, gasper, or othermechanism for alternately securing the suture and releasing it onto thetissue penetrator. The dock may also include an exchange mechanism forde-coupling the suture from the tissue penetrator (e.g., releasing alatch in variations having a latch, unclamping a clamp, etc.). Thus, thedock may be configured to alternately engage and disengage the suturefrom the tissue penetrator and thereby release or retain it in the dock.In some variations the device may be configured to pass a suture fromthe second arm (where it may be pre-loaded into the dock) to the firstarm (via the tissue penetrator) and then back to the second arm (againvia the tissue penetrator) and released back into the dock; thuscompleting two passes through the tissue, which may be in differenttissue locations, since the device may be repositioned between passes.In some variations additional passes through the tissue may becompleted, or the device may be configured for just two passes (aforward and backward stitch).

In practice, the procedure may begin with a 5-10 mm skin incision at theanterior knee through which an arthroscopy camera is inserted. The kneemay then be distended with saline in typical fashion. A camera may bemoved into position such that the meniscus tear can be clearlyvisualized. Varus or valgus stress may be placed across the knee to openup the joint space in typical fashion. FIG. 23 illustrates the anatomyreferred to herein.

The meniscus repair suture passer device may then be inserted throughanother 5-10 mm incision created in the skin at the anterior knee. Suchincisions are used for typical or accessory knee arthroscopy portals.The distal end of the device traverses the skin and enters the fat padin the anterior compartment (see arrow 2305). Gentle pressure allows thedevice to slide though the fat pad and into the space between the femurand tibia. The surgeon may choose to lower his/her hand as the curved orbent distal end of the upper arm follows the curvature of the femoralcondyle allowing access to the posterior or peripheral knee. The distalend region of the upper arm is then positioned approximated above themeniscus tear. In some embodiments the superior capsule may be pushedperipherally with the distal aspect of the upper arm to allow themeniscus apex to flex superiorly (illustrated in FIG. 24A-24C), thusaiding in later extension of the lower arm beneath the meniscus. Thelower arm is then extended distally underneath the meniscus to bepositioned.

For example, in FIG. 24A-24C, the tip of the upper arm is used to applyoutward pressure on the capsule just superior to the peripheral meniscustissue. In doing so, the central aspect of the meniscus 2405 flipsupward a few degrees allowing easier access for the lower arm to slideunder (inferior) to the meniscus. This may allow easier exposure for thelower arm to slide under (inferior) to the meniscus and, may also permita deeper (larger) “bite” of tissue to be obtained during the initialpass, thus more tissue can be incorporated into the repair.

In these variations, the suture may pass through both meniscus andadjacent material, all while preventing damage to vascular structuresfeeding the meniscus and surrounding/supporting structures. For example,peripheral tissue may be captured within the distal opening formedbetween the upper and lower arms of the device in a way that the suturepathway (following the tissue penetrator) arcs through the capsulebehind (peripheral) to the tear during the first few needleadvancements/shuttle exchanges and a second pass may then go through themeniscus tissue itself. Passing in this manner may capture the repairtissue in a way that is optimal for repair and has no risk of damagingthe common peroneal nerve or popliteal artery. The arching first pass ofthe device may allow the capture and repair of more tissue withoutdeleteriously plunging into the back of the knee.

Any of the variations of the shuttle passers described herein may alsoinclude suture guides, channels or controls to direct the suture as itis passed through the tissue. The suture channels may be open or closed,and may be cavities or channels that are formed within the arms, tissuepenetrator(s) and intermediate regions of the device. The channels maybe coated or formed to reduce friction or regions that the suture maycatch or tangle on. Control of the suture may be important to theworking of any of the devices described herein.

Although the foregoing invention has been described in some detail byway of illustration and example for purposes of clarity ofunderstanding, it is readily apparent to those of ordinary skill in theart in light of the teachings of this invention that certain changes andmodifications may be made thereto without departing from the spirit orscope of the appended claims.

We claim:
 1. A method of repairing a torn meniscus using a suture passerhaving a distal first arm and a distal second arm and a proximalelongate body extending in a distal to proximal long axis, the methodcomprising: forming a bend between the distal second arm and the longaxis; placing distal region of the second arm of the suture passeradjacent to the superior surface of the meniscus, wherein the second armis bent relative to the long axis; extending the first arm of a suturepasser distally in the long axis so that the first arm is adjacent tothe inferior surface of the meniscus and so that the distal regions ofthe first and second arms of the suture passer form a distal-facing,angled opening in which at least a portion of the meniscus ispositioned; and extending and withdrawing a tissue penetrator across theopening between the first and second arms to pass a suture between thefirst and second arms.
 2. The method of claim 1, wherein placing thedistal region of the second arm comprises applying outward pressure onthe capsule just superior to the peripheral meniscus tissue.
 3. Themethod of claim 1, wherein extending the first arm comprises sliding thefirst arm distally relative to the long axis after placing the distalregion of the second arm adjacent to the superior surface of themeniscus.
 4. The method of claim 1, wherein extending the first armcomprises sliding the first arm distally relative to the long axis to afully extended position.
 5. The method of claim 1, wherein extending thefirst arm comprises sliding the first arm distally relative to the longaxis until a stop is reached.
 6. The method of claim 1, whereinextending and withdrawing the tissue penetrator comprise extending andwithdrawing the tissue penetrator along a curved path between the firstand second arms.
 7. The method of claim 1, wherein extending andwithdrawing the tissue penetrator across the opening between the firstand second arms to pass a suture between the first and second armscomprises extending the tissue penetrator from within the first arm,through tissue, and engaging a dock within the second arm beforewithdrawing the tissue penetrator back into the first arm.
 8. The methodof claim 1, wherein extending and withdrawing the tissue penetratoracross the opening between the first and second arms to pass a suturebetween the first and second arms comprises extending the tissuepenetrator from within the first arm, through tissue, and engaging asuture held by the second arm, and withdrawing the suture with thetissue penetrator back into the first arm.
 9. The method of claim 1,further comprising repositioning the suture passer without removing thesuture passer from the meniscus, wherein repositioning the suture passercomprises moving the first arm proximally relative to the long axis ofthe device.
 10. The method of claim 1, further comprising repositioningthe suture passer without removing the suture passer from the meniscus,wherein repositioning the suture passer comprises moving suture passerlongitudinally relative to the meniscus.
 11. The method of claim 1,further comprising extending and withdrawing the tissue penetratoracross the opening between the first and second arms to pass a suturebetween the first and second arms a second time.
 12. The method of claim1, further comprising repositioning and extending and withdrawing thetissue penetrator across the opening between the first and second armsto pass the suture between the first and second arms multiple times. 13.A method of repairing a torn meniscus using a suture passer having adistal first arm and a distal second arm and a proximal elongate bodyextending in a distal to proximal long axis, the method comprising:forming a bend in a distal region of the second arm relative to the longaxis; placing the bent distal region of the second arm adjacent to thesuperior surface of the meniscus; extending the first arm of a suturepasser distally relative to the long axis, to position the first armadjacent to the inferior surface of the meniscus, so that the distal endregions of the first and second arms of the suture passer form av-shaped distal-facing opening in which at least a portion of themeniscus is positioned; passing a suture through the meniscus byextending a tissue penetrator from the first arm, across the openingbetween the first and second arms, and through the meniscus to thesecond arm, and withdrawing the tissue penetrator back into the firstarm.
 14. The method of claim 1, wherein forming a bend comprisesmanipulating a control on a distal handle region of the suture passer toform a bend in the second arm.
 15. The method of claim 1, whereinforming a bend comprises forming a bend between the distal region of thesecond arm relative to the long axis before or while placing the distalregion of the second arm adjacent to the superior surface.
 16. A methodof repairing a torn meniscus using a suture passer having a proximalelongate body extending in a distal to proximal long axis, a distalfirst arm configured to extend and retract in the long axis, and adistal second arm configured to form a bend relative to the long axis,the method comprising: placing the second arm of the suture passeradjacent to the superior surface of the meniscus, wherein the distalregion of the second arm is bent relative to the long axis; sliding thefirst arm of the suture passer distally so that the first arm isadjacent to the inferior surface of the meniscus, so that at least aportion of the meniscus is between the first and second arms of thesuture passer within a distal-facing opening; and extending andwithdrawing a tissue penetrator across the opening between the first andsecond arms to pass a suture between the first and second arms.